Updated Announcement of the November 2013 Software Release

102 Pages·2013·0.76 MB·English

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850

Medicare Plan Payment Group
Innovative Healthcare Delivery Systems Group

DATE: August 20, 2013

TO: All Medicare Advantage, Prescription Drug Plan, Cost, PACE, and Demonstration
Organizations Systems Staff

FROM: Cheri Rice /s/
Director, Medicare Plan Payment Group

Cathy Carter /s/
Acting Director, Innovative HealthCare Delivery Systems Group

SUBJECT: Updated Announcement of November 2013 Software Release
The Centers for Medicare and Medicaid Services (CMS) continues to implement software
improvements to the enrollment and payment systems that support Medicare Advantage and
Prescription Drug (MAPD) programs. This letter provides detailed information regarding the
planned release of systems’ changes scheduled for November 2013. This release focuses on
improving CMS system efficiency and plan processing.
This letter updates the “Announcement of November 2013 Software Release” sent on August 14,
2013. In this version, we corrected the International Classification of Diseases Code Indicator
references in attachments C and D by replacing “9 = ICD-9; 10 = ICD-10” with “9 = ICD-9; 0 =
ICD-10”.
The November 2013 Release changes are as follows and may require plan action:
1. Segment ID Assignment for Year End Processing
2. Modifications to the Medicare Advantage Prescription Drug System (MARx) Other
Health Insurance (OHI) Notification Records
3. Medicare Secondary Payer (MSP) Improvements, Part 2: Using Coordination of
Benefits (COB) Information in Processing MSP Payment Reductions
4. Jurisdiction Change Enhancements
5. Update Monthly Model Output Report (MOR) for Additional Part C Risk
Adjustment Model Version 22
6. Medicare Advantage (MA) Enrollee Risk Assessment Code

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1. Segment ID Assignment for Year End Processing
With the November 2013 release of the Medicare Advantage Prescription Drug System (MARx),
CMS is reducing the need for plans to submit Transaction Reply Code (TRC) 77 (Segment ID
Change) transactions. In 2012, CMS introduced default Segment ID assignments. Currently,
plans can submit an enrollment for a segmented plan while leaving the Segment ID field blank
and MARx automatically determines the Segment ID assignment according to the enrollee’s
residence State County Code (SCC).

The November release will include the following changes:

• MARx determines a plan’s default segment as the one with the lowest premium rates.
• MARx expands automatic assignment of Segment ID in year-end processing for
situations involving a change in a plan’s segment definitions from one year to the next:
• The composition of segments, i.e., which SCCs belong to which segment, is
changing.
• SCCs are added or removed from the plan service area.
• Segments are added or removed.

Rollovers from one plan to another or rollovers between plans in different contracts constitute
enrollment changes and are not affected by this change. Medicare Advantage Organizations (MAOs)
will continue to use the existing Health Plan Management System rollover mechanism for inter-plan
rollovers, even when the “from” or “to” plan is segmented. The following TRCs are modified
according to this update. TRC 316 is modified to reflect the new default Segment ID logic. TRC
317 is modified to reflect that it is issued in cases where an enrollment spans a period when there
are two different Segment IDs since one is not valid for part of the timeframe.
• Updated TRCs: TRC 316, Default Segment ID Assignment; TRC 317, Segment ID
Reassigned, Attachment A.

2. Modifications to the Medicare Advantage Prescription Drug System (MARx) Other
Health Insurance (OHI) Notification Records
As a result of the October release, plans receive new information in the Coordination of Benefits
(COB); Validated Other Health Insurance Data File. The total length of the file expands from
1000 to 1100 bytes. The additional information includes 25 occurrences of Claim Diagnosis
Code, each with a corresponding International Classification of Diseases (ICD) Code Indicator:
‘9’ for ICD revision 9 and ‘0’ for ICD revision 10. The Claim Diagnosis Code occurrences are
available on both the Primary and Supplemental records. The previous five occurrences of Claim
Diagnosis Code in positions 526 through 575 of the Primary record are no longer used and are
replaced with filler (spaces).

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Also, the Coverage Effective Date starting in position 282 of both the Primary and Supplemental
records will now hold the Submitted Effective Date, which is defined as: Other (non-Medicare)
Insurance Effective Date originally submitted by supplemental drug insurers.
These updates are incorporated into the following PCUG Appendices Record Layouts:
• F.5.2: Detail Records: Indicates the Beginning of a Series of Beneficiary Subordinate
Detail Records, Attachment B.
• F.5.3 Primary Records: Subordinate to Detail Record (Unlimited
Occurrences), Attachment C.
• F.5.4 Supplemental Records: Subordinate to DTL (Unlimited
Occurrences), Attachment D.

3. Medicare Secondary Payer (MSP) Improvements, Part 2: Using Coordination of
Benefits (COB) Information in Processing MSP Payment Reductions
As a result of the November release, CMS is changing the Monthly MSP Information Data File
(Header Code CMSMSPIH). These changes correspond to the internal table MARx uses to
process MSP payment reductions.
The following fields are added to the file:
• Creation Date (accretion date),
• MSP Originating Contractor,
• MSP Updating Contractor,
• Delete indicator,
• Validity Indicator, and
• MSP Last Maintenance Date.

This information assists plans in determining the actions needed to update or verify MSP
information. MARx also adjusts payment for individual plans by accepting pending Electronic
Correspondence Referral System (ECRS) submissions or “I” records as valid records.
Starting in October 2013, CMS will record these new data fields as changes occur in the internal
table. Those changes will appear in the December 2013 Monthly MSP Information Data File that
is sent to the plans in November. In January 2014, a refresh of all MSP data from January 1,
2009 forward is scheduled to populate all fields and correct some reported data discrepancies
The updated Monthly MSP Information Data File is attached:
• Monthly Medicare Secondary Payer (MSP) Data File, Attachment E.

4. Jurisdiction Change Enhancements
As a result of various life changes, the agency (either the Social Security Administration (SSA)
or Railroad Retirement Board (RRB) agency) which provides a retirement benefit to a
beneficiary may change. When this occurs, the agency that has health insurance jurisdiction and
the beneficiary’s Health Insurance Claim Number (HICN) will change. CMS requires accurate
information about whether SSA or RRB has health insurance jurisdiction so that data is sent to
the correct agency. Expediting the recognition of the jurisdiction change allows CMS to forward
withheld premiums to the plans in a more timely manner.
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This update enhances jurisdiction identification and tracking by recognizing a change of an SSA
HICN to an RRB HICN, or vice versa, as the start of a new jurisdiction period. If the beneficiary
is in premium withholding with the agency, CMS attempts to establish withholding under the
new jurisdiction. Two new Transaction Reply Codes (TRCs) are added to notify plans of the
jurisdiction changes and the attempt to set up withholding with the new agency.
In addition, an RRB beneficiary does not need an SSN to have premiums withheld. With this
update, SSNs will no longer be required for RRB withholding requests.
The following new TRCs are attached:
• TRC 319, RRB to SSA Beneficiary Jurisdiction Change; TRC 320, SSA to RRB
Beneficiary Jurisdiction Change, Attachment F.

5. Update Monthly Model Output Report (MOR) for Additional Part C Risk
Adjustment Model Version 22
The November 2013 System Release modifies the current monthly MOR for Part C (PTC) to
support the new PTC risk adjustment model as stated in the 2014 Payment Notice published on
April 1, 2013(http://www.cms.gov/Medicare/Health-
Plans/MedicareAdvtgSpecRateStats/Announcements-and-Documents.html). The PTC MOR file
currently includes two detail record types and updates to include a third detailed record type. The
updated record types are:

• Record Type A: the current PTC aged/disabled risk adjustment model (model version
12) for non-PACE, non-ESRD beneficiaries.
• Record Type B: the current PACE and ESRD models (model version 21)
• Record Type C: the new 2014 Part C aged/disabled risk adjustment model (model
version 22), as discussed in the 2014 Announcement.

The new 2014 PTC MOR file format is attached. The following summarizes the updates to the
PTC MOR:

1. The PTC MOR data file format for 2014 is modified to support the new CMS V22 model.
• A new Detail Record Type 'C' that reports the factor indicators for the CMS HCC
V22 model scores is defined.
• The PTC MOR for 2014 continues to report the V21 Detail Record Type 'B' for
PACE and/or ESRD beneficiaries.
• Because 2014 risk scores will be a blend of risk scores calculated on the current
(V12) model and the new (V22) model, the PTC MOR for 2014 reports both a V12
Detail Record Type 'A' and a V22 Detail Record Type 'C' for non-PACE, non-ESRD
beneficiaries. This is a change to the current 'one record per beneficiary' rule.
• Plan sponsors can reference the new CMS HCC V22 model, published in April 2013,
for definitions of the factors in the new V22 Detail Record Type 'C' for non-PACE,
non-ESRD beneficiaries.
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2. The Part C MOR report file format for 2014 changes to display 2 sets of data (V12 and V22)
for the same Medicare Advantage (MA) beneficiary. The program name in the report header
changes.

3. The Record Type A (model version 12) and Record Type B (model version 21) do not
change and remain the same for 2014.

Please note: The Part D MOR data file format and report file format do not change, except for
the program name in the report header of the report file.

The tables of the 2014 RAS Part C MOR Layout are attached:

• 2014 Risk Adjustment System (RAPS) Part C (PTC) Monthly Model Output Report
(MOR) Record Layout, Attachment G.

6. Medicare Advantage (MA) Enrollee Risk Assessment Code

Effective for dates of service starting 1/1/2014, risk adjustment data submitted by MA
organizations to CMS’ Risk Adjustment Processing System (RAPS) are accepted if the new field
“Risk Assessment” is populated.

The Risk Assessment field must contain one of the following values:

A. Diagnosis code comes from a clinical setting.

B. Diagnosis code comes from a non-clinical setting and originates in a visit where all
requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or
Subsequent Annual Wellness Visit were met.

C. Diagnosis code comes from a non-clinical setting and originates in a visit where all
requirements specified at 42 CFR 410.15(a) for a First Annual Wellness Visit or
Subsequent Annual Wellness Visit were not met.

The requirements for a First Annual Wellness Visit and Subsequent Annual Wellness Visit are
defined in regulation at 42 CFR 410.15(a).

Reminder: All diagnoses submitted for risk adjustment purposes must come from an acceptable
provider type. Thus, submitted diagnoses identified in non-clinical settings must originate from
an acceptable Physician Specialty Type described in Section 2.2.1.3 on physician data in the Risk
Adjustment Participant Guide found at http://www.csscoperations.com.

The new RAPS file format requires that one of the three acceptable Risk Assessment Codes is
assigned to each cluster. Errors are returned for anything other than an acceptable code in the
Risk Assessment Code field if the date of service is 1/1/2014 or greater.

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MA organizations are advised that there are no certification requirements for submission of the
new RAPS format. MA organizations may immediately begin submitting the Risk Assessment
Codes; however the field is not a requirement until January 2014.

For information regarding the new RAPS error codes and/or record layout, MA organizations
should contact CSSC Operations at 1.877.534.2772 or by e-mail
at [email protected].

The new RAPS Error Codes and the RAPS Record Layout are attached:

• RAPS Error Codes, Attachment H.
• RAPS Record Layout, Attachment I.

Plans are encouraged to contact the MAPD Help Desk for any issues encountered during the
systems update process. Please direct any questions or concerns to the MAPD Help Desk at
1-800-927-8069 or e-mail at [email protected].

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Attachment A: Updated TRCs: TRC 316, Default Segment ID Assignment; TRC 317, Segment
ID Reassigned
Attachment A: TRC 316, Default Segment ID Assignment; TRC 317, Segment ID
Reassigned
Short
Code Type Title Description
Definition
316 I Default Segment DEFAULT A default Segment ID is assigned because the beneficiary is
ID Assignment SEG ID out of area for the Contract/PBP. For years prior to 2014,
the default Segment ID is the Segment with the lowest
valid Segment ID for the Contract/PBP. For years 2014 and
later, the default Segment is the Segment with the lowest
premiums.
Plan Action: Verify the beneficiary’s address is correct.
Submit a Residence Address Change if appropriate.
317 I Segment ID SEG ID A Segment ID is reassigned because updated address
Reassigned REASSIGN information are received. The updated address information
could result from either a Plan- submitted Residence
Address Changed (Transaction Type 76) or a State and
County Code change notification.
A Segment ID is reassigned for one of the following
reasons:
• Updated address information is received. The updated
address information could results from either a Plan-
submitted Residence Address Change (Transaction Type
76) or a State and County Code change notification.
• An Enrollment Transaction (Transaction Type 61) or
Segment ID Change (Transaction Type 77) is received
for a segmented Plan where part of the enrollment has a
terminated Segment ID. Examples include:
A retroactive enrollment that spans more than
o
one year and the Segment ID is not valid for
both years
An enrollment that is effective at the end of one
o
year and the Segment ID is not valid for the
upcoming year
The effective date of the reassignment is reported in field
18.
Plan Action: Verify the Segment ID is correct. Submit a
Residence Address Change or a Segment ID change if
appropriate.
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Attachment B: F.5.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences)
Attachment B: F.5.2: Detail Records: Indicates the Beginning of a Series of Beneficiary
Subordinate Detail Records
Data Field Length Position Format Valid Values
Record Type 3 1-3 CHAR "DTL"
HICN/RRB Number 12 4-15 CHAR Spaces if unknown
SSN 9 16-24 ZD 000000000 if unknown
Date of Birth (DOB) 8 25-32 CHAR YYYYMMDD
0 = Unknown, 1 = Male, 2 =
Gender Code 1 33 CHAR
Female
Contract Number 5 34-38 CHAR
Plan Benefit Package 3 39-41 CHAR
Action Type 1 42 CHAR 2 = Full replacement
Filler 1058 43-1100 CHAR Spaces

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Attachment C: F.5.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences)
Attachment C: F.5.3 Primary Records: Subordinate to Detail Record (Unlimited
Occurrences)
Data Field Length Position Format Valid Values
Record Type 3 1-3 CHAR "PRM"
HICN/RRB Number* 12 4-15 CHAR Spaces if unknown
SSN* 9 16-24 ZD 000000000 if unknown
Date of Birth (DOB)* 8 25-32 CHAR CCYYMMDD
0 = Unknown, 1 = Male, 2 =
Gender Code* 1 33 CHAR
Female
Rx ID Number* 20 34-53 CHAR
Rx Group Number* 15 54-68 CHAR
Rx BIN Number* 6 69-74 CHAR
Rx PCN Number* 10 75-84 CHAR
Rx Plan Toll Free
85-102 CHAR
Number* 18
Sequence Number* 3 103-105 CHAR
COB Source Code* 5 106-110 CHAR 11100 Non Payment/Payment
Denial
11101 IEQ
11102 Data Match
11103 HMO
11104 Litigation Settlement
BCBS
11105 Employer Voluntary
Reporting
11106 Insurer Voluntary
Reporting
11107 First Claim
Development
11108 Trauma Code
Development
11109 Secondary Claims
Investigation
11110 Self Report
11111 411.25
11112 BCBS Voluntary
Agreements
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Attachment C: F.5.3 Primary Records: Subordinate to Detail Record (Unlimited Occurrences)
Data Field Length Position Format Valid Values
11113 Office of Personnel
Management (OPM) Data
Match
11114 Workers'
Compensation Data Match
11118 Pharmacy Benefit
Manager (PBM)
11120 COBA
11125 Recovery Audit
Contractor (RAC) 1 (April
Release)
11126 RAC 2 (April Release)
11127 RAC 3 (April Release)
P0000 PBM
S0000 Assistance Program
Note: Contractor numbers
11100 – 11199 are reserved
for COB
MSP Reason 1 111 CHAR A Working Aged
(Entitlement Reason B ESRD
from COB) C Conditional Payment
D Automobile Insurance, No
fault
E Workers Compensation
F Federal (public)
G Disabled
H Black Lung
I Veterans
L Liability
Coverage Code* 1 112 CHAR A = Hospital and Medical
U = Drug (network benefit)
V = Drug with Major Medical
(non-network benefit)
W = Comprehensive,
Hospital, Medical, Drug
(network)
X = Hospital and Drug
(network)
Y = Medical and Drug
(network)
Z = Health Reimbursement
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